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INTRODUCTION

For the past 15 years, Lancaster General Health (LGH) has offered a summer externship program for student nurses. This program has welcomed, mentored, and embraced 518 nursing students from over 40 colleges and universities. Although the number of externships offered nationwide has been decreasing recently due to the economic downturn, LGH has remained committed to this program as a win-win situation for student nurse externs, nurse preceptors, patients, nurse managers, and nursing administration.

As this is the fifteenth anniversary of this extern program, it seems fitting to pause and reflect on its progress to date. This article will define a nurse extern, explain the program and its objectives, highlight the uniqueness of the LGH externship, and share some perspectives of externs, faculty, preceptors, nurse managers, and nurse administrators. Lastly, it will note the collaborative effort the program requires to make it a success, and focus on its benefit to LGH.

NURSE EXTERN

As defined by the Hospital Association of Pennsylvania,¹ a nurse extern is a student nurse who is within one year of graduating from a program approved by a state board that leads to an associate or baccalaureate degree in nursing. The extern has expressed a desire to advance their skills and knowledge in two clinical specialty areas.

There are more than 90 applicants annually. Since only 20 externs are currently accepted each year, appointments are highly competitive and acceptance is prestigious. Applications are submitted online, and in addition to the usual demographic information and work history/resume, the applicants require a solid grade point average (3.0 or greater), two letters of recommendations from clinical nursing faculty, a statement of clinical preferences, and a written questionnaire about the applicants goals and expectations for the program. For the 2014 year, the top candidates also received a phone interview.

The extern works collaboratively with the registered nurse and may carry out many basic functions of the nurse. Externs are not permitted to administer medications, draw blood, or administer blood products, but they are encouraged to actively observe these procedures. And though externs are encouraged to assist their teams in any way needed, their experience should not be limited to the duties of a nurse’s aide. Externs receive a check-list of skills similar to the list used for orientation of new LGH nurses, which may be used to guide their practice.

LGH NURSE EXTERN PROGRAM/OBJECTIVES

The LGH externship is committed to the extern’s professional development. The 8½ week program consists of two clinical blocks, each four weeks in duration, in two different clinical units of the extern’s choosing. It utilizes a partnership model² in which each extern is assigned a registered nurse preceptor(s) who works side-by-side with the extern, co-experiencing the day to day operations of a nurse. They share a patient assignment and together collaborate in the care of the patients. In addition, a nursing faculty member rounds every day (0700-1530) to discuss patients and to provide clinically related teaching.

The objectives of the program are to:

1. Increase clinical exposure to acute care areas in order to build on experiences in their nursing programs;
2. Challenge the extern to think critically while using a holistic perspective toward patient care;
3. Foster relationships between the nurse extern and the RN role models and other members of the interdisciplinary health care team;
4. Enhance socialization into the culture of nursing to increase the likelihood that externs will choose an acute care facility as their specialty area upon graduation;
5. Provide opportunities for externs to select the areas in which they wish to practice as professionals;
6. Introduce externs to a realistic clinical employment setting, thus promoting a better transition from student to professional nurse;
7. Encourage networking opportunities while a student;
8. Provide exposure to the fast-paced, specialized and technologically intensive world of nursing;
9. Introduce the extern to the culture of a Magnet hospital and recognize the significance of this designation from a nursing perspective.

This is a paid position with no college credits offered. Externs sign a contract stating they will follow all appropriate LGH nursing policies and procedures. In addition, if they are interested, externs may shadow for a day in other departments such as open heart surgery, emergency department, IV team, wound and ostomy nursing, cardiac catheterization lab, or other specialty areas.

PROGRAM HIGHLIGHTS SPECIFIC TO LGH

Other highlights of the externship at LGH include a weekly “lunch-n-learn” where externs share lunch as well as experiences and patient-related stories for learning purposes.³ This activity was started as the result of feedback from previous externs and was implemented as a way for externs to stay connected with one another and foster professional relationships. Another highlight is weekly post-clinical conferences which cover a variety of topics such as national patient safety goals,^4,5 healthy work environments,⁶ arterial blood gas analysis, specialty areas of nursing, caring for a patient on a ventilator, rapid patient assessment and the role of rapid response teams, lab value analysis, and clinical application.

At LGH there are also unit-specific nurse ambassadors who embrace the extern and orient him or her to unit-specific items.

PERSPECTIVES OF NURSE EXTERNS

Nursing students who participate in externships do so mainly to gain clinical experience and to reap the benefits of hands-on experiential learning.^3,7,8 Others want to experience different nursing specialties not covered in their nursing education such as perianesthesia nursing. Or, they may want to see what it’s like to work at a Magnet hospital such as LGH, to see if this is where they would like to commence their professional career. Many externs say they “want to gain confidence, improve their assessment skills, and see the daily routine of the nurse.”^3,7,8

Externs recognize that the gap between education and practice can seem insurmountable and see this summer commitment as a way to narrow the gap and make the transition to practice easier. Externs also want to “make their senior year of nursing school less daunting by gaining all the clinical knowledge they can.”⁸ Externs like this experience and often report, “they learned more in eight weeks than they did in their entire nursing school.” This is largely due to the fact that externs are less anxious when they don’t have the pressure of care plan grades, clinical quizzes, and pathophysiology clinical conferences. Externs state they are able to “focus solely on learning and advancing professionally.”

Many externs state they “want to understand the workings of the interdisciplinary health care team, what does that mean, who are the players, and what is my role as the nurse on this team.” Another extern went on to clarify that he “sees this team for brief periods of time as a student during clinical rotations, but exactly how to be a patient advocate on this team is unclear.” By the end of the externship another extern verbalized, “this really allowed me to see how the team is so well orchestrated and how everyone has each other’s back, as well as working for the patient.”^8,9

Tammy L. Gardner (quoted with permission), an extern in 2013, wrote: “During the summer of 2013, I had the privilege of participating in the Externship program. The program was an excellent opportunity for me to experience the day-to-day life of a medical/surgical RN and to practice my assessment and nursing skills. Each day I worked one-on-one with an RN, and was also afforded the opportunity to work with wound nurses, respiratory technicians, and to follow patients through endoscopy and other procedural areas. In addition to gaining a great deal of experience and insight, I also developed a rapport with the nurses and nurse managers on my assigned floor which later led to a full time position. I feel very strongly that this greatly enhanced my ability to practice during my final semester of nursing school and was instrumental in my gaining employment with LGH.”

PERSPECTIVES OF NURSING FACULTY

Most faculty members recognize that educational programs cannot teach every aspect of healthcare. Nurse educators often recommend summer externships to students as a way to gain clinical experience and knowledge, and to be immersed in the environment of nursing.^2,8,10 Educators have noted increased cultural¹⁰ and geriatric awareness.¹¹

Faculty members in this program work with students from many different educational programs, and can identify weaknesses in the education system. For example, this year it was recognized across the 2014 extern cohort that they were not aware of how to take report in the morning from the nurse going off duty. They could not make meaning of the information or use it in a way that informed their clinical decision-making. As a result two remedies were initiated: first, faculty recognized the need to teach this skill in the regular nursing school program; and second, the externship faculty added a post clinical conference provided by one of the nurse managers to be sure externs practice this very important nursing skill.

PERSPECTIVES OF NURSE PRECEPTORS

Nursing preceptors enjoy working with externs for many reasons. Many LGH preceptors are curious about the responsibilities of nursing educators and view this experience as a way to see if they would like to pursue a career in clinical education. Preceptors also see this as a way to showcase what they do on a day to day basis.

The LGH externship committee recognizes that the LGH preceptors are the “glue that holds this program together.” The externship would not be possible without the commitment and dedication of the preceptors who have worked diligently with the externs on a day to day basis, going above and beyond to include the externs in their practice and patient care activities.

PERSPECTIVES OF NURSE MANAGERS NURSE ADMINISTRATORS

Nurse managers embrace externs and see this as a “way to get to know future employees and determine if the extern would be a good fit for their unit upon graduation.” Managers have an opportunity to preliminarily assess the externs initiative, work ethic, interpersonal skills, and interest in a particular specialty area.^7,8 This externship also allows managers the opportunity to develop their nurses and expand on their teaching, preceptorship, and leadership skills. Nurse managers select preceptors who are exceptional team members, good role models, enjoy teaching, and have the wisdom and desire to share their clinical experiences.

Hospital administrators and managers see such programs as a recruitment tool that may positively impact orientation of new RNs.⁷ They recognize that externs usually seek employment at institutions in which they have completed externships. New nurses who have been externs are familiar with the hospital computer system, general hospital policies and procedures, unit specific items, organization structure, and Magnet hospital nursing professionalism. While the length of the orientation should not be changed for an extern, externs and managers have reported that the orientation process is much less intimidating.

Furthermore, administrators believe that participation in an extern program positively impacts retention of new nurses. Externs have a better understanding of the role of the nurse and LGH’s expectations from its nurses. Externs become aware of the demands of working full time, as they are not just experiencing the short clinical assignments which students have in nursing school.

OUTCOMES OF EXTERN PROGRAMS

Although there is a paucity of research on outcomes of nursing extern programs, a descriptive, qualitative study investigating transformational learning validated changes in nursing externs’ assumptions, values, and beliefs regarding nursing as a profession and career choice.9 This study, derived from individual discussions, focus groups, and reflective surveys, was carried out with 78 nurse externs from baccalaureate, associate, or diploma programs. Assumptions were affirmed, values were validated, and some core beliefs were banished. Examples regarding affirming assumptions as stated by two externs are,

“I always assumed communication is very important, but during this externship I witnessed my nurse preceptor communicating, and I now see how communication is much more multidimensional. The nurse communicates verbally not only with the patient, but also with family members, doctors, and other nurses as well. Communication in the written form must be concise in limiting computer spaces.”

A second extern stated, “What it really means to be a professional nurse is to communicate as a patient advocate when collaborating with doctors. I assumed that the patient was primarily the physician and nurses’ responsibility, but I now feel the nurse is ultimately responsible. Doctors can write whatever, but patients are our professional responsibility, we are with them at the bedside constantly.”

While nurse externs valued their organizational skills, ability to prioritize patient care, and the importance of patient teaching at the beginning of the externship, they reported valuing these job responsibilities even more so at the end of the externship.

Regarding banishing core beliefs, 65% of the externs in this study felt that their personal core beliefs about nursing as a profession were transformed as a result of the externship program. One belief regarding what a great nurse is was banished. One extern shared, “I used to believe that every nurse eventually went on to become a ‘great’ nurse. But I now realize, the nurse who goes the extra mile, sees the patient holistically, and also treats the family compassionately is the great nurse.” Another stated, “My personal belief about nursing changed positively, I believe that as a nurse I truly impact patients, and families, as well as impact their future. An extern faculty member taught me ‘never underestimate the gift of giving yourself.’ I learned a positive attitude and compassion—even in the smallest amount—can impact a patient’s outcome. I now believe I can be a great nurse, because I can always offer myself in a genuine way to my patients and treat them like I would like to be treated.”

At the outset of the externship externs questioned their belief in themselves and wondered if they even had what it takes to be a nurse. As a result of their participation, this diminished core belief was transformed through increased self-confidence. For many externs, it was the newly found “belief in themselves” that was most transforming.

A large percentage of these externs are hired at LGH. Data are currently being analyzed related to the retention rate to see if the retention rate is better for externs than it is for other new graduate nurses.

CONCLUSION

To augment their clinical experience in school and to ease the gap between education and the real world of nursing practice, many nursing students (externs) have chosen to participate in the LGH summer nursing extern program. The LGH program has been very successful for the past 15 years. Preceptors, managers, and administrators have all played key roles in acculturating externs, treating them like colleagues, helping them to feel like “insiders,” and assisting them to think like a nurse who has an important role on a very important health care team in a Magnet institution.

REFERENCES

1. Hospital and Health System Association of Pennsylvania. (2008). A guide to developing extern programs. Harrisburg: HAP Nurse Externship Advisory Committee.

2. Gregory S, Bolling DR, Langston, NF. Partnerships and new learning models to create the future perioperative nursing workforce. AORN Journal, 2014; 99(1): 96-105.

3. Mang L. Seize the opportunity an externship offers. Nursing, 2011; 41(2): 9-10.

4. The Joint Commission. (2012). National patient safety goal #2: Improve communication among caregivers. Retrieved from http://www.jointcommission.org/

5. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington DC: National Acadamies Press.

6. Association of Critical-Care Nurses, 2005; http://www.aacn.org/hwehome.aspx?pageid=331&menu=hwe (accessed July 2, 2014).

7. Ramirez YI, Zimmerman R, Judson LH. A student externship program: Academia and service collaboration. Journal of Nursing Regulation, 2013; 4(1): 39-44.

8. Rhoads J, Sensenig K, Ruth-Sahd LA, Thompson E. Nursing externship: A collaborative endeavor between nursing education and nursing administration. Dimensions of Critical Care Nursing, 2003; 22: 255-258.

9. Ruth-Sahd L A, Beck J A, McCall C. Transformative learning during a summer nursing externship program: The reflections of senior nursing students. Nursing Education Perspectives, 2010; 31(2): 78-83.

10. Lee A Y, Ruth-Sahd L A. When the east meets the west: An application of folk medicine in the Amish community. Journal of Lancaster General Hospital, 2011; 6(4): 114-118.

11. Souder E, Beverly CJ, Kitch S, Lubin SA. Early exposure to geriatric nursing through an externship program. Nursing Education Perspectives, 2012; 33(3): 166-9.